Authors: Shopp JD et al. Acad Emerg Med 2015 Sep 22.
A meta-analysis found that a Daniel Score >5 is associated with a higher probability of shock from PE.
Treatments for hemodynamically stable patients with confirmed pulmonary embolism (PE) vary from outpatient anticoagulation to systemic fibrinolysis. Guidelines recommend that the choice of treatment be based on risk stratification via electrocardiogram (ECG), biomarker, and imaging (echocardiogram or computed tomography) findings.
The Daniel score was developed as a prognostic ECG-based prediction tool for increased pulmonary artery pressure as a sign of cardiac stress (Chest 2001; 120:474). These authors (one of whom led the development of the Daniel score) performed a systematic review and meta-analysis to determine the prognostic value of each of the score’s components (tachycardia, S1Q3T3 pattern, incomplete and complete right bundle branch block, and T-wave inversion in leads V1–V4), as well as ST-segment elevation in lead aVR and atrial fibrillation.
Ten studies involving 3007 patients with PE (mean age, 60 years; 43% men) were included in the analysis. Rates of shock ranged from 1% to 27%; mortality ranged from 5% to 23%. Each of the six findings was predictive of circulatory collapse. Patients who developed shock from PE had significantly higher mean Daniel scores than those who did not develop shock (5.9 vs. 2.6 points on a 21-point scale).
ECGs are obtained for all patients with pulmonary embolism, and the Daniel score allows for rapid risk stratification based on this readily available test. The authors suggest a Daniel score >5 as a marker of greater risk for hemodynamic collapse. While prospective studies are needed to evaluate this cutoff, given the performance of the individual characteristics, patients who meet this cutoff should be considered for more intensive monitoring and treatment or, at least, not be considered for outpatient therapy.